The document summarizes the anatomy of arteries in the neck and head region. It describes the branches and course of the common carotid artery, external carotid artery, internal carotid artery, and their major branches including the maxillary artery, lingual artery, facial artery, occipital artery, and ophthalmic artery. It provides details on ligations and surgical approaches for various arteries. Key anatomical structures and landmarks are highlighted.

1. Carotid in Neck ,
ECA, IMA & its
branches
-Dr.Malarvizhi. R
MBBS (SRM MCH&RC, Chennai, IN)
DLO (MMC, Chennai, IN)

2. Carotid in Neck
• Right common carotid from brachiocephalic trumk
• Left common carotid directly from aortic arch
• Ascend along trachea and larynx without giving off any branches
• Together with IJV and vagus nerve forms neurovascular bundle
of neck covered by a separate sheath
• Inferior portion covered by SCM
• Midway along it passes a nonmuscular CAROTID trianglr
covered only by skin, platysma and superficial cervical fascia

5. • NO BRANCHES
• At the level of C6, CCA can be compressed against thick
anterior tubercle
• At level of C4 bifurcates into External and Internal carotid
arteries
• The bifurcation dilates to form CAROTID sinus , baroreceptors
• Also have CAROTID BODY , chemoreceptors

7. External Carotid Artery
• Branches-Anterior branches & Medial, Posterior and Terminal
branches
• Anterior Branches
• Superior Thyroid Artery
• Infrahyoid branch
• Superior Laryngeal artery
• Cricothyroid branch
• Sternocleidomastoid branch
• Glandular branch
• Lingual Artery
• Facial Artery

8. • Medial Branch
• Ascending Pharyngeal Artery
• Branches into Posterior Meningeal and Inferior Tympanic Arteries
• Posterior Branches
• Occipital Artery
• Posterior Auricular Artery
• Terminal branch
• Maxillary Artery
• Superficial Temporal Artery
• Frontal branch
• Parietal branch
• Transverse facial branch
• Zygomatico-orbital branch

12. • Ligature of Superior thyroid artery in thyroid surgery should be
made close to the gland to avoid injury of External Laryngeal
nerve
• Ligature of lingual artery done in first part before it gives any
branches to tongue or tonsil in surgical removal of tongue.

13. External Carotid Artery Ligation
• Ligation
• Done at 2 points
• Artery exposed at its origin and ligature above Superior Thyroid
Artery – upper part of neck , superficial and deep structures of neck
• Ligation higher up, behind the angle of lower jaw – maxillary artery
injuries

14. Ligation Of ECA in Carotid
Triangle
• Skin incision at the level of angle of mandible behind anterior
border of SCM muscle, continued downward to the level of
cricoid cartilage
• Platysma, superfical sheath of SCM incised , muscle exposed and
retracted, deep layer of SCM head is visible and IJV through it
• Fascia in front of vein is cut to expose the arteries

16. Ligation Of ECA in
Retromandibular Fossa
• Skin incision- at line starting at the tip of mastoid process,
circling the mandibular angle, continuing forward below the
mandible one inch
• Passing sclapel through skin and posterior fibers of platysma, the
retromandibular vein or EJV is located , tied and cut
• Branches of greater auricular nerve cut- permit mobilization of
cervical lobe of parotid gland

17. • Attachment of parotid capsule to the anterior border of SCM
severed with scalpel
• Parotid gland retracted, posterior belly of Digastric , stylohyoid
muscle is visible. above this stylomandibular ligament can be
palpated if lower jaw of the patient is pulled forward.
• This movement – widens the entrance into retomandibular fossa,
tenses the stylomandibular ligament
• Pulsations of ECA are felt, isolated and tied.

19. Ligation Of Lingual Artery
• LIGATION OF LINGUAL ARTERY :
• Incision – circling the lower pole of submandibular gland.
• Posterior part – towards tip of mastoid ;
• anterior part – towards chin.
• Skin, platysma, deep fascia incised, submandibular gland
exposed , lifted,tendon of diagastric visible.
• Free border of mylohyoid muscle ascertained, hypoglossal nerve
identified. Digastric tendon pulled downwards –enlarges the
digastric triangle, hyoglossus muscle visible.
• Muscle divided bluntly, in the gap of its vertical fibers lingual
artery found & ligated

20. Facial Artery
• Given off at carotid triangle just above level of tip of greater
cornua of hyoid bone
• Cervical course, passes through submandibular region and finally
enters face
• Tortuous
• Branches- Cervical and Facial
• Facial branches
• Anterior – large. Anastomoses with opposite side
• Inferior labial
• Superior labial
• Lateral nasal
• Posterior- small , unnamed. Anastomoses with transverse facial and
infraorbital arteries

21. • Cervical branches
• Ascending palatine Artery
• Tonsillar Artery
• Submental Artery
• Glandular branches to submandibular salivary glands and lymph
nodes

22. Facial Artery Branches

23. Ligation Of Facial Artery
• LIGATION OF FACIAL ARTERY. Exposed --at the point
crossing the lower border of mandible . Using contracted
masseter as a landmark, pulse of facial artery felt at point situated
anterior to the attachment of masseter. Artery is accompanied by
facial vein & crossed superficially by marginal mandibular branch
of facial nerve. Taking this into consideration, incision -- at least
half inch below the border of mandible & parallel to it. Skin,
platysma, deep fascia are cut , soft tissues retracted, pulse of
facial artery felt. Artery-- isolated, tied & cut.

24. Nasal Blood Supply

26. Maxillary Artery
• Largest branch of ECA
• Divided by Lateral Pterygoid muscle into 3 parts
• First ( Mandibular) part
• 5 branches
• Second ( Pterygoid ) part ( superficial to muscle)
• 4 branches
• Third (Pterygopalatine) part
• 6 branches

27. Maxillary Artery

29. Maxillary Artery Branches

30. Maxillary Artery Embolization
• Internal maxillary artery embolization is done for intractable epistaxis
• Embolization is used to block blood flow through a blood vessel
by placing tiny polyvinyl spheres in the blood vessel. This stops
the nosebleed and prevents complications from continued loss
of blood.

31. Pterygopalatine Fossa

32. Maxillary Artery Ligation
• Two approaches –
• 1) Transantral Approach. 2) Intraoral Approach.
• 1) Transantral Approach – Transantral approach for the third division
of maxillary artery. It is currently the most widely used arterial ligation
procedure for controlling posterior epistaxis. In some cases, bilateral
maxillary artery ligation, is required to control unilateral bleeding
because of cross- anastomosis from adominant maxillary artery.
• Procedure – Standard gingival incision 1) Anterior wall of the maxillary
sinus is exposed and removed with special care not to injure the
infraorbital nerve. 2) The posterior wall of the sinus is identified and a
laterally based U- shaped mucosal flap elevated. 3) Positions of the
posterior wall removed to gain exposure to the pterygopalatine fossa
and the branches of the maxillary artery.

33. • Intra-oral approach
• Procedure – Incision at upper gingivobuccal sulcus at the level of
2nd & 3rd molar and continued inferiorly along the ramus of the
mandible. The buccal fat pad is retracted medially or removed and
the attachments of the temporalis muscle to the coronoid process
of the mandible are identified. The temporalis muscle belly may
need to be split and partially dissected from the mandible to gain
access to the artery.

37. Sphenopalatine Artery
• The IMA gives off numerous small branches while still proximal
to the foramen, and it becomes the sphenopalatine artery close to
the sphenopalatine ostium. The SPA is usually 3-5 mm in
diameter, and divides into two larger branches 1.5-2mm in
diameter; usually this occurs in front of the ostium and less
commonly past it.
• The smaller medial arterial branch (septal artery) runs under the
lower part of the anterior wall of the sphenoid sinus to the
posterior nasal septum The larger branch (posterior lateral nasal
artery) distributes variable branches to the middle turbinate and
posterior fontanelle and passes downward over the perpendicular
plate of the palatine bone approximately 1 cm in front of the
end of the middle turbinate (usually, but not always, behind the
level of the posterior sphenoid sinus wall)

38. • The SPA has 3-4 branches coming out of its foramen that lie at
least 0.5 cm deep to the mucosa on the lateral nasal wall. The
vessels split up as soon as they leave the foramen. The anterior
branch of the SPA comes around the crista and can be found as
it runs forward in the lateral nasal wall over the posterior
fontanelle

40. Sphenopalatine Artery Ligation
• A. incision vertical to the posterior portion of the middle
turbinate;
• B. elevation of a posterior and superior mucoperiosteal flap,
reaching the sphenopalatine artery at the level of the
sphenopalatine foramen;
• C. application of vascular clips under direct view;
• D. return of the mucoperiosteal flap to its original position
• (MT: middle turbinate; IT: inferior turbinate; C: choana; arrow:
indicates the sphenopalatine foramen).

42. Anterior Ethmoidal Artery
Ligation
• Endoscopic and Open approach
• Endoscopic Approach
• Open the sinuses and identify the skull base.
• Perform an uncinectomy with identification of the maxillary ostium.
This is a landmark for the floor of the orbit and also guides the
surgeon to the approximate height of the sphenoid ostium.
• Clear the frontal recess and identify the frontal ostium.
• Remove the lower half of the ethmoid bulla and enter the posterior
ethmoids.
• Identify the superior turbinate and remove the inferior third to identify
the sphenoid ostium.
• Enlarge the sphenoid to identify the skull base.
• .

43. • Continue the dissection along the skull base, completely
removing all cells from the sphenoid roof posteriorly to the
frontal ostium anteriorly.
• If indicated because of the need for an entire skull base
resection, an endoscopic modified Lothrop procedure may aid in
exposing the anterior skull base and AEA
• Identify and confirm AEA & PEA by image guidance
• Use Diamond burr to thin the bone overlying AEA
• Remove bone over a broad front over the artery to reduce the
risk of transecting the artery
• After exposing the artery use a bipolar cautery .

45. • Open Approach
• After injecting a local vasoconstrictive agent, make a semicircular
incision (Lynch incision)
• Dissect Soft Tissue Down to Bone. Diploic veins are often identified
here, and bipolar cautery can be used for hemostasis.
• Retract Soft Tissue with a Thin, Malleable Retractor.
• Continue the Dissection Posteriorly until the Nasolacrimal Sac Is
Identified
• This step can be done either with loupes or with a 0-degree endoscope
• Continue the Dissection Posteriorly until the AEA and PEA Are
Identified
• The 24/12/6 rule is useful to identify the arteries
• Ligate the vessels with Bipolar cautery.

47. Internal Carotid Artery
• Begins at the level of the upper border of the thyroid cartiage.
• Consist of four portions.
• Cervical
• Petrous
• Cavernous
• Cerebral

48. Cervical portion
• Runs perpendicularly upward in front of the transverse
processes of the upper three cervical vertebrae.
• Ends at the carotid canal in the petrous portion of the
temporal bone.
• No branches
Petrous portion
• Enters the carotid canal in the petrous portion of the temporal
bone.
• Ascends a short distance.
• Curves forward and medialward.
• Ascends again as it leaves the skull

49. Cavernous Portion
• Artery is situated between the layers of the dura mater
forming the cavernous sinus.
• It is covered by the lining membrane of the sinus.
• Ascends towards the posterior clinoid process.
• Then passes forward by the side of the body of the sphenoid
bone.
• Curves upward on the medial side of the anterior clinoid
process.
• Perforates the dura mater forming the roof of the sinus

50. Cerebral Portion
• After piercing the dura mater on the medial side of the clinoid
process
• Passes between the optic and occulomotor nerves to the
anterior perforated substance at the medial extremity of the
lateral cerebral fissure.
• Gives off its terminal branches

52. ICA Segment Branches
Cervical No branch
Petrous • Caroticotympanic
• Artery of the Pterygoid canal
Cavernous • Cavernous
• Hypophyseal
• Semilunar
• Anterior Meningeal
• Ophthalmic
Cerebral • Anterior Cerebral
• Middle Cerebral
• Posterior Communicating
• Choroidal

53. Ophthalmic Artery
• Divided into two groups
• Orbital group – distributed to the orbit and surrounding parts
• Ocular group – distributed to the muscles and bulb of the eye.
Orbital group
• Lacrimal
• Supraorbital
• Posterior Ethmoidal
• Anterior Ethmoidal
• Medial Palpebral
• Frontal
• Dorsal Nasal
Ocular group
• Central artery of the Retina
• Short Posterior Ciliary
• Long Posterior Ciliary
• Anterior Ciliary
• Muscular

55. Terminal Branches of the ICA
• Anterior Cerebral
• Middle Cerebral
• Posterior Communicating

56. Thanking the INTERNET
• For vast resources (Pictures and photographs) made available to
download for free
• References
• Chaurasia BD
• Elsevier Anatomy for students
• Scott Brown
• Stell & Maran